Rare Presentation of Postpericardiotomy Syndrome After Left Atrial Myxoma Removal

Postpericardiotomy syndrome (PPS) is a known complication of cardiac valve surgery, but it has not been commonly reported as a postoperative complication of cardiac myxoma removal. A 78-year-old female with hypertension and atrial fibrillation presenting with angina was found to have a large left atrial myxoma (7.5 cm × 4.4 cm). The myxoma was resected; however, 1-week postoperation hemoglobin and blood pressure decreased with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Limited transthoracic echocardiogram (TTE) showed moderate pericardial effusion, confirming the diagnosis of PPS. This case highlights the importance of monitoring patients postremoval of myxoma for symptoms of PPS.


Introduction
Postcardiac injury syndrome (PCIS), previously known as Dressler syndrome, comprises autoimmune-mediated pericarditis conditions with risk factors that include myocardial infarction, chest trauma, or cardiac surgery.Postpericardiotomy syndrome (PPS) is a subgroup of PCIS characterized by pericarditis symptoms that may emerge 1 to 6 weeks after cardiac surgery.Here, we report a rare case of PPS postremoval of a left atrial myxoma.

Case Report
A 78-year-old Hispanic female with a history of hypertension and atrial fibrillation (AF) CHA2DS2-VASc 4/HAS-BLED 3/ORBIT 4 on dabigatran presented to the emergency department (ED) with anginal symptoms.Troponins were negative, electrocardiogram (EKG) showed AF with controlled ventricular rate and no ischemic changes.D-dimer was elevated (Table 1).Subsequent computed tomography (CT) PE did not show evidence of pulmonary embolism, but revealed a large left atrial mass consistent with myxoma (Figure 1).Initial transthoracic echocardiogram (TTE) showed severe left atrial dilatation, atrial myxoma measuring 7.5 cm × 4.4 cm, and small pericardial effusion (Figure 2, Table 2).The myxoma caused secondary mitral valve dysfunction, acute-on-chronic diastolic heart failure (left ventricular ejection fraction (LVEF) 55-60%) and intermittently compressed her coronary arteries causing anginal symptoms.Cardiology conducted a left heart catheterization which showed large left atrial branches feeding the myxoma.Computed tomography surgery resected the left atrial myxoma via pericardiotomy and ligated the left atrial appendage, reducing the risk of stroke.
Cardiac electrophysiology (EP) then performed a transesophageal echocardiogram-guided cardioversion with prompt reversion to AF, which may have been due to inflammation from the recent pericardiotomy.Amiodarone 200 mg QD, metoprolol 12.5 mg BID, and Eliquis 5 mg QD were continued with a 1-month follow-up to reconsider cardioversion after postoperative inflammation subsided.Perioperatively, the patient received several blood transfusions, otherwise remaining stable.One week postoperatively, her hemoglobin and blood pressure decreased without overt signs of bleeding.Computed tomography chest showed 2 mediastinal hematomas and suggested a moderate pericardial effusion.With incidental pericardial effusion on admission, a limited TTE was repeated and found a moderate pericardial effusion consistent with pericarditis (Figure 3).Erythrocyte sedimentation rate was elevated at 40, and C-reactive protein (CRP) was elevated at 4.8 (Table 3).Given her new findings of moderate pericardial effusion with pericarditis, she was diagnosed with PPS and started on ibuprofen 600 mg TID and colchicine 0.6 mg BID.After extensive discussion, it was decided to temporarily hold anticoagulation for outpatient follow-up.

Discussion
Myxomas are the most common primary cardiac tumor in adults, with over 75% of cases originating in the left atrium. 1 Postpericardiotomy syndrome is characterized by 2 out of the 5 criteria: fever, anterior chest pain worsened with inspiration and supine position, pericardial friction rub, pericardial effusion, and pleural effusion with elevated CRP. 2,3It is a common complication of cardiac surgery occurring in about 10% of patients, most commonly after aorta, aortic valve, and mitral valve surgery. 4,57][8] Studies conducted to identify risk factors of developing PPS among patients undergoing coronary artery bypass graft (CABG) and valve replacements found increased risk with younger age, lower platelet counts, reduced body weight, blood transfusions, and renal dysfunction. 2,9Our patient received several blood transfusions postoperatively, which may have increased her risk for developing PPS.Management of PPS is similar to idiopathic pericarditis with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine.The COPPS-2 trial investigated the perioperative use of colchicine placebo among cardiac surgery patients and saw a reduction in the incidence of PPS compared with placebo. 10Although no patients in the trial underwent pericardiotomy specifically for cardiac myxomas, it may be worth considering administering prophylactic colchicine to myxoma surgery patients to prevent PPS.It is worth addressing that the trial demonstrated a 2-fold increase of gastrointestinal adverse effects, 11.7% in the placebo group versus 20.0% in the colchicine group, and similar discontinuation rates among the two groups, which suggests that colchicine pretreatment may not be applicable to all patients.Future studies should be conducted to explore the risk factors linked to PPS in patients who have undergone cardiac myxoma removal to facilitate more effective identification of these patients, which gives the treatment team a chance to decide if the patient is a good candidate for colchicine prophylaxis.
The American College of Cardiology published an expert analysis in 2015 which reviewed studies looking at prophylactic treatments for PPS. 11There was a study of 1019 adult patients who underwent cardiac surgery which showed taking 600 mg of ibuprofen QID or 24 mg indomethacin QID for 10 days was effective in reducing the incidence of PPS. 12 However, there was also a retrospective study of 177 pediatric patients who underwent cardiac surgery which found that aspirin did not reduce the incidence of PPS. 13 Thus, there is no consensus on standard of care prophylaxis at the moment for PPS.Given the potential positive research findings for ibuprofen or colchicine for PPS prophylaxis, it would be beneficial to have a discussion about prophylaxis in patients similar to our case who are undergoing surgery for myxoma removal.
Some challenges with diagnosing our patient were the confounding chest pain postsurgery as it was difficult to determine if the pain was attributed to PPS or the postsurgery healing process.However, additional labs such as ESR and CRP and imaging can aid the diagnosis of PPS.Our case highlights the potential for PPS to develop in patients who have undergone cardiac myxoma removal.Prophylactic treatment should be discussed for every patient undergoing  cardiac myxoma removal surgery.Following surgery, patients should be closely monitored for the emergence of symptoms consistent with PPS.

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ICXXX10.1177/23247096231217858Journal of Investigative Medicine High Impact Case ReportsFeng et al case-report20232023 1 University of Texas Rio Grande Valley School of Medicine, Edinburg, USA 2 Valley Baptist Medical Center, Harlingen, TX, USA